Weight Loss Surgery and Health Insurance: Shouldn't They Go Together?

[Alex Brecher 10,494]

Innumerable consumers, lawmakers, and healthcare professionals alike celebrated at the passage of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare, in 2010. The ACA expanded healthcare coverage to millions of Americans and promised to put this country’s broken healthcare system on the mend. The law came with an unprecedented focus on preventive medicine and wellness, and nationwide improvements in obesity treatment seemed to be coming.

Many weight loss surgery candidates and healthcare professionals, however, have been disappointed. The ACA has plenty of shortcomings when it comes to bariatric surgery. More than half of states do not cover bariatric surgery. Among those that do, many put up barriers to getting the procedure that prevent some weight loss surgery candidates from being able to qualify for reimbursement.

Advances in Obesity Coverage Under the ACA

The ACA does have some provisions that help to reduce obesity on a national level. It includes $15 billion in funding for wellness and disease prevention programs, many of which will target obesity. Another preventive measure is that the ACA requires restaurant chains to post calorie counts on menus. The ACA requires Medicare providers to cover obesity screening and counseling when you go to the doctor, and many healthcare insurance providers are also providing these services.

Another provision of the ACA is that employees in qualifying programs are reimbursed for their healthy behaviors. If they do not smoke, maintain a healthy weight, and have blood pressure and blood cholesterol levels within the normal range, employees can get up to $800 per year. Employees with obesity can get cash back if they lose at least 10 percent of their body weight, but will not receive the money until they reach a BMI under 30.

The ACA also forbids health insurance providers to deny you coverage based on pre-existing conditions. Since obesity is now recognized as a disease, according to the American Medical Association (AMA), health insurance providers cannot refuse to accept you just because of your obesity. You also cannot be denied coverage just because you had weight loss surgery in the past.

Measurable Benefits Expected With These ACA Provisions

Each of the above provisions can lead to small amounts of weight loss. For example, counseling for weight loss can lead to a loss of about 5 percent of body weight on average. This modest weight loss can improve blood sugar, blood pressure, and other measures of health, and it can save you, your provider, and the government money.

Limitations/More Is Needed

However, if you are a weight loss surgery candidate, losing 5 percent of body weight will still leave you with a good amount of excess body weight. Obesity-related health conditions such as diabetes and arthritis are still a threat, and your obesity is likely to continue to interfere with your daily life. Bariatric surgery can be effective against obesity, and it can also fight diabetes and other conditions. With its potential to treat obesity, you might expect it to be covered under the ACA. Unfortunately, only some states cover it.

State by State Differences in Healthcare Coverage – Benchmark Plans

The ACA requires states to offer acceptable health insurance plans, but these plans may vary by state. The plans that states can offer to fulfill the requirements are known as benchmark plans. These plans set the minimum level of benefits that a state must provide, and the benefits are based on current plans within a state. So, states where competing private plans do not cover weight loss surgery are not likely to offer Obamacare plans that cover weight loss surgery.

To make matters worse, the states that do not cover weight loss surgery tend to be the states with the highest rates of obesity. In effect, the more likely you are to have obesity, the less likely you are to live in a state that covers bariatric surgery.

You can find out more about each state’s benchmark plan from the government’s The Center for Consumer Information & Insurance Oversight (CCIIO) within the Centers for Medicare and Medicaid Services (CMS) site.

Which States Cover Weight Loss Surgery?

So far, 22 states cover bariatric surgery.

• Arizona, California, Delaware, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Rhode Island, South Dakota, Vermont, West Virginia and Wyoming
  

Five states and cover weight loss programs, but do not necessarily cover weight loss surgery.

• California, District of Columbia, Massachusetts, Michigan, New Mexico
  

Twenty-eight states do not cover bariatric surgery or other extensive obesity treatment.

• Alabama, Alaska, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington and Wisconsin
  

Coverage Often Seems Reluctant

Even if your health care coverage includes weight loss surgery, it can come with a lot of hoops. For example, you may need to wait a certain number of months or diet to lose a certain amount of weight before you can get the surgery. Your plan may not cover the type of weight loss surgery that you are hoping to get, especially in the case of newer surgery types such as the vertical sleeve gastrectomy (gastric sleeve).

There can also be a lifetime limit of one surgery, which does you no good if your first surgery did not work. If surgery is a disease, shouldn't you be entitled to treatment that works?

What Can You Do?

You can advocate for making weight loss surgery a required service under Obamacare by reaching out to state and federal representatives. If you live in a state where bariatric surgery is already covered, contact your representatives in Congress. If you live in a state where bariatric surgery is not yet covered, contact your Congress people, and also contact your state representatives.

In your letter, phone call, or email to your representative, explain what bariatric surgery means to you and to the thousands of others like you. Explain why you need it to lose weight, and how you feel that it could impact your life. Describe the obstacles and health problems that you face because of obesity. Your goal is to convince the representative that weight loss surgery needs to be covered.

If weight loss surgery is the only effective treatment for obesity, it should be included in a healthcare plan. Otherwise, we will continue to struggle with these same problems because not everyone can afford the thousands of dollars it takes to get the surgery done.

[Susan909 52]

Contacting your local represenitive really does help.

Keep contacting them and tell them what you would like to see change, until change happens. Use your voice.

[BariatricGirl 220]

Great article....such a shame that some of the states that need it most (like Texas) are excluded. I am hopeful however because it IS getting better. Literally thanks to not being held hostage over preexisting conditions, my husband and I are able to get real insurance for the first time in 12 years because my gastric bypass made me a leper in the eyes of the insurance company. (we are self employed) Because I could get a well woman's exam they found something that would have killed me if left unchecked. I was also able to get a colonoscopy which was about ten years overdue especially since my mom lost her life to colon cancer.

I think we are getting closer and like Susan said....contacting your representative really does help in most states. I'm a glass half full girl and I'm grateful for the progress made so far and looking forward to making more. Thanks Alex for a very informative article. I so hope that one day in the near future they will finally acknowledge food addiction so that thousands can possibly get the help they need.

[7 Bites_Jen 479]

GREAT article. I had no idea this was even an issue with ACA. I wonder how they treat aftercare by people that have already had the surgery?

Interesting that Texas doesn't cover it. Although the Medicaid program DOES cover the gastric bypass (after several hoops). You would think that the ACA would as well!

I agree 100% that each of these states needs to rethink this!!

To find your representative:
http://www.house.gov/representatives/find/

Or you can go to your state's website!

[Alex Brecher 10,494]

You can find some great state by state resources here:

http://asmbs.org/resources/ehb-access-toolkit